Nicaragua - Health Sector Reform Project

(1-/j (--; - / Document of The World Bank FOR OFFICIAL USE ONLY Report No. P-6175-NI MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT IN THE AMOUNT EQUIVALENT TO SDR 10.8 MILLION TO THE REPUBLIC OF NICARAGUA FOR A HEALTH SECTOR REFORM PROJECT NOVEMBER 24, 1993 MICROGRAPHICS Report No: P- 6175 NI Type: MOP This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. CURRENCY AND EQUIVALENT UNITS US$1 = 6.2 Nicaragua Cordoba (C) (November 1993) SDR 1.0 = U.'$1.3934 (November 1993) WEIGHTS AND MEASURES 1 Hectare (ha) = 10,000 m2 I Metric Ton (mt) = 1,000 kg 1 Kilometer (km) = 1,000 m 1 Cubic Meter (m3) = 1,000 liters (1) 1 Liter (1) = 1,000 milliliters (ml) FISCAL YEAR January 1 - December 31 GLOSSARY OF ACRONYMS GDP Gross Domestic Product IDA International Development Association IEC Information, Education. and Communication INSSBI Nicaraguan Social Security Institute MIS Management Information System MOH Ministry of Health PCU Project Coordinating Unit PHC Primary Health Care SILAIS Departmental Health Units FOR OFFICIAL USE ONLY NICARAGUA HEALTH SECTOR REFORM PROJECT CREDIT AND PROJECT SUMMARY Borrower: The Republic of Nicaragua Beneficiaries: Ministry of Health (MOH) and Social Security Institute (INSSBI) Amount: SDR10.8 million (US$15 million equivalent) Terms: Standard IDA terms with 40 years matwrity including 10 years of grace Financing Plan: Local Foreign Total - US$ million - Government of Nicaragua 2.1 0.0 2.1 IDA 2.9 12.1 15.0 Norway 0.5 2.5 3.0 Total Financing 5.5 14.6 20.1 Economic Rate of Return: Not applicable Staff Appraisal Report: Report No. 12393-NI; dated November 24, 1993 Map: IBRD No. 25188 This document has a restricted distribution and may be used by recipients only in the performance of their official duties. Its contents may not otherwise be disclosed without World Bank authorization. MEMORANDUM AND RECOMMENDATION OF THE PRESIDENT OF THE INTERNATIONAL DEVELOPMENT ASSOCIATION TO THE EXECUTIVE DIRECTORS ON A PROPOSED CREDIT TO THE REPUBLIC OF NICARAGUA FOR A HEALTH SECTOR REFORM PROJECT 1. I submit for your approval the following memorandum and recommendation on a proposed Development Credit to the Republic of Nicaragua for SDR10.8 million (US$15 million equivalent) to help finance a Health Sector Reform project. The proposed Credit would be repayable on standard IDA terms with forty years maturity, including ten years of grace. The total project cost is estimated at US$20.1 million. 2. Background. Nicaragua is one of Latin America's poorest countries with a per capita GNP estimated at US$422 in 1992. Public spending in health increased significantly from 1.1 percent of GDP in 1978 to 4.4 percent of GDP in 1993, one of the higher percentages in Central America. The public health service was expanded to cover about 73 percent of the population in 1993. However, health gains have not been as great as one might have expected from the increased resource allocations, principally because of low efficiency in the use of sector resources and poor management. Thus, health indicators continue to show large deficiencies, as reflected in an infant mortality rate of 72/1,000 and a maternal mortality rate of 159/100,000. 3. Several factors account for Nicaragua's inability to improve significantly the health status of its population: (a) the rapid population growth (3.4 percent p.a.) together with constrained fiscal resources make it difficult for the Government to provide quality services and further expand coverage; (b) up to 1992, the management of the Ministry of Health (MOH) was overly centralized and the budgetary practices and resource allocation system provided no incentives to improve efficiency in service delivery at the local level; (c) weak personnel management resulted in a skills mix that does not match the demand for services, a lack of clear salary, training, and career incentive policies, and a shortage of nurses; (d) the cunent model of primary health care (PHC) relies too much upon less cost-effective curative care, and a number of preventive programs are operated in parallel, resulting in waste of resources and of patient and staff time; (e) there is an acute shortage of drugs and medical supplies, resulting from their inefficient procurement and distribution, storage, and use; and (f) because of the lack of a proper maintenance system, health facilities are in disrepair, especially hospitals, resulting in poor quality and delays in service provision and discouraging cost recovery. Given the Government's tight fiscal situation, the expected drop in external aid, and the relatively low level of cost recovery, the present health system may not be sustainable unless major reforms are undertaken. 4. Government Strategy. As a critical part of its long-term social sector strategy, the Government has committed itself to improve the efficiency, effectiveness, and quality of health services, particularly to the poor, and to reduce inequities in access to basic health care. The principles underlying this policy are stated in the Government's health sector policy letter issued in support of the project. To implement its strategy, the Government will: (a) decentralize health services by allocating resources on a per capita basis to Departmental Health Units (the SILAIS) based on annual management arrangements using key performance monitoring indicators, focusing MOH's new role on formulating policies and supervising program implementation, designing and implementing clear salary, training, and career incentive policies for MOH staff, and improving the nurse:doctor ratio; (b) implement a redefined PHC model focusing on preventive measures, integration of parallel service programs, and delegation of simple health tasks to nurses and auxiliary nurses; the MOH will strongly promote family planning as an integral part of the PHC model by making modem contraceptives widely available and improving -2- quality of outreach services and of information, educLtion, and communication (IEC) activities; (c) strengthen suply and distribution of pharmaceutical products by procuring only essential pharmaceuticals, increasing private sector distribution, strengthening inventory management, promoting rational use of drugs, and increasing cost recovery; (d) rehabilitate health facilities to improve quality and efficiency of service; and (e) strengthen cost recovery at he secondary level, principally by selling a package of efficient and quality health services to the affiliates of INSSBI kSocial Security Institute), which covers about 25 percent of the economically active population at present. 5. Project Objectives. The objective of the project is to enhance the Nicaraguan population's health status by supporting the implementation of the Government's new strategy for the health sector. In particular, the project would aim to: (a) improve the institutional capacity and management systems of MOH by decentrali7ing services and financial resources to the SILAIS and introducing performance arrangements and monitoring indicators, new administrative and accounting systems, revised budgeting mechanisms, and strengthened management information systems (MIS); (b) increase the quality of service delivery by supporting the implementation of a redefined PHC model responsive to local epidemiological conditions, with special emphasis on preventive care and family planning, improving procurement, supply and distribution of drugs and medical supplies, rehabilitating and maintaining facilities and equipment, and improving staff productivity; and (c) strengthen the financing of the sector by increasing cost recovery at the secondary level. 6. Project Description. The project has six components: (a) Institutional Strengthening of MQ (US$2.6 million, equivalent to 12.9 percent of total project cost including contingencies) would provide technical assistance to (i) help decentralize budget implementation, improve resource allocation, introduce service provision arrangements with the SILAIS, and increase cost recovery, (ii) design and carry out human resources develo--ent and manpower planning and training programs, and (iii) strengthen the MIS; (b) Primary Health Care (US$7.0 million, or 34.8 percent) introduces a new PHC model nationwide, where preventive care is emphasized and parallel programs, including family planning, are integrated at the local level; the project would support PHC by financing (i) essential drugs for priority interventions, (ii) training of health services delivery personnel, (iii) IEC activities, (iv) rehabilitation of PHC facilities in seven of the poorest SILAIS, and (v) a monitoring and evaluation system; (c) Pharmaceutical Supply and Distribution System (US$3.2 million, or 15.9 percent) would improve the supply and distribution of essential drugs and pharmaceutical supplies by (i) conducting studies and providing technical assistance to improve policy, regulation, and financing, including operating a pilot private pharmacy within an MOH hospital, (ii) improving inventory management, strengthening MIS, rehabilitating storage areas, and increasing private sector distribution, and (iii) assessing the nature and level of irrational use of pharmaceuticals and starting to reduce its incidence; (d) Rehabilitation and Maintenance of Hospitals (US$5.3 million, or 26.4 percent) would finance (i) emergency rehabilitation subprojects for hospitals and (ii) the design of a proper maintenance system, including a study to analyze the impact on recurrent costs so that these costs may be properly budgeted for by the MOH; (e) Technical Assistance to INSSBI (US$1.0 million, or 5 percent) would help design and implement (i) a health insurance program, for which INSSBI would purchase health services from the MOH and the private sector and (ii) a workmen's compensation program and carry out the preliminary economic and actuarial studies to evaluate the feasibility of reforming the pension system; and (f) Project Administration (US$1.0 million, or 5 percent) would finance consultant services and operating costs of the Project Coordination Unit (PCU). -3- 7. Project Cost and Financing. The total project cost, estimated at US$20.1 million, would be financed by an IDA Credit of US$15 million equivalent, or 75 percent of total project cost, US$2.1 million equivalent from the Government, and US$3 million from the Government of Norway. Retroactive financing of up to US$0.75 million (5 percent of Credit amount) would be provided for eligibie payments made after October 1, 1993; funds would be used for urgently needed initial technical assistance, training, and project administration activities. A breakdown of costs and financing plan are shown in Schedule A. Amounts and methods of procurement and disbursement and the disbursement schedule are shown in Schedule B. A timetable of key project processing events and the status of Bank Group operations in Nicaragua are given in Schedules C and D, respectively. The Staff Appraisal Report No. 12393-NI, dated November 24, 1993, is also attached. 8. Project Implementation. The project would be implemented over three and a half years by the MOH and INSSBI, whose institutional capacity would be strengthened through significant technical assistance. The MOH has been radically transformed and improved during the last year and would have the capacity to implement the project and absorb the technical assistance to be provided. The MOH has established a clear strategy for the sector and is committed to the project. During project preparation, the MOH has already taken important policy and management decisions and undertaken successfully a number of pilot programs which will help facilit.ite project implementation significantly. It has already started to use technical assistance funds available from the Social Investment Fund (FISE) project (Cr. No. 2434-NI, November 1992) to strengthen the management of the SILAIS. Potential weaknesses in implementation capacity have been addressed through clarity of project design, definition of clearly monitorable objectives, phasing in of reforms, complemented by technical assistance and strong supervision. In addition to the Government's commitment, increased private secondary health care financing would help ensure the project's sustainability. 9. Project Sustainability. By supporting Government reforms on priority policy areas, the project would have a significant positive impact on the institutional capacity and financial equilibrium of the health sector. MOH's institutional capacity for sustaining the reform would be strengthened through project implementation. Also, due to a number of measures to reduce the costs of providing services and concomitantly inroducig mechanisms to recover a share of those costs, the MOH would have strengthened its financial capacity to sustain the implementation of the reform measures supported under the proposed operation. 10. Lessons from Previous IDA Involvement. Since the proposed project would be the first IDA-supported health operation in Nicaragua, the lessons learned reflect only experiences from Bank group projects in Latin America and elsewhere and from IDA projects in Nicaragua in other sectors. All of the most frequently encountered problems have been taken into consideration in the project design. Most importantly, the Government's commitment has been ensured through: (a) close involvement of the MOH and INSSBI in project preparation; (b) a policy letter where the Government undertakes to at least maintain the share of central revenues currently allocatec to the health sector; and (c) consensus-building by the Government to mitigate objections that entrenched interest groups may have to the reforms. 11. Rationale for IDA Participation. The proposed health sector project is in line with the overall country assistance strategy regarding social sector reform within a fiscal policy that needs to be tightly managed. Following up on the social sector analysis completed in early 1993, the Government requested IDA to play a leading role in assisting Nicaragua design and implement its health sector reform program. The Government values the Bank Group's sector experience with other Latin American countries such as Chile and Costa Rica, which have recently been -4- undertaking successful health sector reforms and expects that experience with those reforms can be usefully adapted, with IDA's assiotance, to the Nicaraguan context. As Chairman of the Consultative Group Meeting, the Bank has been instrumental in mobilizing donor financing for the health sector reform. IDA's presence in the sector would complement aid programs of several donor agencies and facilitate the coordination of donor activities by providing a policy framework for health sector investmcats. The project would complement IDA's Economic Recovery Credit (Cr. 2302-NI, September 1991) as well as the short-term poverty alleviation efforts supported under the FISE Credit. The project would further encourage the Government to move ahead with its health reform program and would lay the framework for further reforms of the health sector that could be supported through future operations pursuing similar financial and quality objectives. 12. Actions Agreed. Durin negotiations, the following main agreements were reached with the Government on: (a) a review of budget decentralization and agreement or an action plan with IDA by April 30, 1995, with implementation starting by May 31, 1995; (b) a review of draft resource allocation system on a corrected per capita basis by September 30, 1994 and starting implementation of this system on a pilot basis in at least five SILAIS no later than January 1, 1995; (c) a study to be completed by June 30, 1995 to (i) review results of the corrected per capita resource allocation pilot, (ii) assess expansion of pilot to all SILAIS, and (iii) assess feasibility of introducing a resource allocation system based on the per capita cost of delivering health care services; results of this study would be discussed at the mid-term review and implementation of agreed action plan would start by September 1, 1995; (d) a review of the current cost accounting system with IDA by December 31, 1994, assessment of exansion to all hospitals and SILAIS, and starting implementation of agreed action plan by March 1, 1995; (e) making service provision arrangements satisfactory to IDA a condition of transfer of funds from the MOH to the SILAIS; (t) a review of implementation of service provision arrangements in all SILAIS with IDA by October 31, 1994 and starting implementation of agreed action plan by January 1, 1995; (g) completion of a pilot program for promotion of delivery of pharmacy services by the private sector in one of the MOH's hospitals by June 30, 1995, with results to be discussed with IDA at the mid-term review and an agreed action plan to start by August 1, 1995; (h) studies on cost recovery, health manpower market, pharmaceutical policy and regulation, rational drug use, and maintenance and recurrent costs would be completed, their results discussed with IDA, and respective agreed action plans would be carried out, according to timetables agreed at negotiations; (i) minimum counterpart funds of US$2.1 million to be provided by the Government; (j) annual reviews by November 30 of each year; and (k) in-depth mid-term review by June 30, 1995. As conditions of Credit effectiveness, the Government would hae: (a) made service provision arrangements with at least three SILAIS; and (b) entered into a Subsidiary Agreement with INSSBI for the use of project funds. Conditions for disbursement would be that: (a) for any of the project SILAIS under the PHC component, service provision arrangements with MOH would have been made; (b) for human resources development, a satisfactory Operational Manual would have been adopted; (c) for computer hardware, agreement would have been reached with IDA on an action plan for implementing the new MIS; (d) for pharmaceutical products and medical supplies, a satisfactory reduced essential drugs list would have been presented; (e) for the infrastructure and equipment subcomponent, a satisfactory Operational Manual would have been adopted; (f) for the PHC component, a satisfactory supervision manual with monitoring and evaluation indicators would have been presented; and (g) for rehabilitiation of hospitals, a satisfactory Operational Manual would have been adopted. 13. Environmental Aspects. The project would have no adverse environmental impact and would have a C rating. -5- 14. Poverty Category. The project would support a program of targeted intervention. The project would help reduce poverty through: (a) establishment of a decentralized and improved health care delivery system which would immediately benefit the underserveO poor populations in remote areas; (b) continued strong emphasis on free PHC care services for the poor; and (c) improvement of resource management and mobilization which woWld enable the Government to continue providing free essential services to the poor. 15. Project Benefits. The project would have a significant impact on the financing of the health sector by reducing the cost of providing services and introducing mechanisms to recover a share of those costs. If a realistic 50 percent implementation success rate were reached, total savings of US$2.7 million would result from: (a) efficiency gains in pharmaceutical procurement, distribution, and prescription practices; (b) integration of parallel PHC programs; (c) improved maintenance and rehabilitation of physical facilities and medical equipment. Improvements in efficiency and quality of health service delivery would contribute to improving health status and reduce infant and maternal mortality. On the revenue side, additional revenue of US$13.8 million would be generated through increased cost recovery at the secondary level. Should all these savings be efficiently invested by the MOH in extending services, coverage could be increased from 70 to 90 percent of the population. 16. Project Risks. The main risks are: (a) the feasibility of accomplishing a reform program given Nicaragua's weak institutional base; (b) possible delays by MOH to implement policy reforms because of likely opposition from affected interest groups (such as unions, medical associations, pharmaceutical suppliers); and (c) Government counterpart financing constraints. Risk (a) would be mitigated by a gradual implementation of reforms in line with building of institutionat capacity through technical assistance and the training of managers who would implement the reforms. Risk (b) would be mitigated by donors' united support of reform, the MOH's strong commitment to reform, and the Governmeit's consensus building through the staging of seminars with various interest groups to discuss the ref-rm. Risk (c) would be mitigated by limiting the level of Government participation to 10 percent of total project cost and receiving an annual commitment from the Government to provide counterpart fumds. 17. Recommendation. I am satisfied that the proposed Credit would comply with the Articles of IDA and recommend that the Executive Directors approve the proposed Credit. Lewis T. Preston President Attachments Washington, D.C. Novemer 24, 1993 -6- Schedule A Page 1 of 1 NICARAGUA HEALTH SECTOR REFORM PROJECT ESTIMATED COSTS & FINANCING PLAN ESTIMATED COSTS Local Foreign Total - US$ million Institutional Strengthening of MOH 0.4 2.0 2.4 Primary Health Care 1.7 4.8 6.5 Pharmaceutical Supply System 0.7 2.4 3.1 Rehabilitation and Maintenance of Hospitals 1.4 3.4 4.8 Technical Assistance to INSSBI 0.2 0.7 0.9 Project Administration 0.8 0.2 1.0 Total Baseline Cost 5.2 13.5 18.7 Physical Contingenzies 0.1 0.5 0.6 Price Contingencies 0.2 0.6 0.8 TOTAL COSTI' 5.5 14.6 20.1 FINANCING PLAN Local Foreign Total -US$ million- Government of Nicaragua 2.1 0.0 2.1 IDA 2.9 12.1 15.0 Norway 0.5 2.5 3.0 Total 5.5 14.6 20.1 I/ Net of taxes and duties. -7- Schedule B Page 1 of 2 NICARAGUA HEALTH SECTOR REFORM PROJECT PROCUREMENT METHODS BY CATEGORY (in US$ million) Non-IDA Category ICB LCB Other Financed Total Civil Works and Materials 2.2 2.1' V 4.3 (1.9) (1.8; (3.7) Goods and Equipment 0.6 0.6 0.6!' 2.2 4.0 (0.6) (0.6) (0.5) (1.7) Vehicles - -- 0.4 - 0.4 (0.4) (0.4) Medical Equipment - - 0.60 - 0.6 (0.6) (0.6) Pharmaceutical Products & Supplies - - 3.3W - 3.3 (2.0) (2.0) Management Information System 0.9 -- -- - 0.9 (0.8) (0.8) Training - -- 1.7 0.8 2.5 (1.7) (1.7) Consultants - - 4.1 - 4.1 (4.1) (4.1) TOTAL 1.5 2.8 12.8 3.0 (0.1 (1.4) (2.5) (11.1) (15.0) Figures in parentheses are the amounts estimated to be financed by IDA. To be procured through price quotations from at least three suppliers (local shopping) To be procured through Limited International Bidding (LIB) To be procured through international shopping (US$0.2 million) and LIB (US$0.4 million) To be procured through international shopping (US$1.3 millioi.) and LIB (US$2.0 million) -8- Schedule B Page 2 of 2 NICARAGUA HEALTH SECTOR REFORM PROJECT DISBURSEMENTS Withdrawals of the Proceeds of the Credit Amount of the Credit Category Allocated (expressed Percent of Expenditures in US$ million to be financed equivakat) 1. Civil Works for Part C 0.6 90% 2. Goods (other than medical 0.4 100% of foreign expenditures, 100% of local equipment and pharmaceuticals) for expenditures (ex-factory cost) and 75% of Part C expenditures for other items procured locally 3. Goods for Part E 0.1 100% of foreign expenditures, 100% of local 1, expenditures (ex-factory cost) and 75% of expenditures for other items procured locally 4. Goods for PCU 0.3 100% of foreign expenditures, 100% of local expenditues (ex-factory cost) and 75% of expenditures for other items procured locally 5. Medical Equipment 0.6 100% 6. Pharmaceutical Products 2.0 100% of expenditures up to an aggregate amount of US$800,000; 50% up to an aggregate amount of US$1,200,000; and 25% for the remainder 7. Training for Parts B & C 0.9 90% 8. Training for Part E 0.2 90% 9. Consultant Services for Parts A, B, 3.3 100% C&D 10. Consultant Services for Part E 0.6 100% 11. MIS 0.9 90% 12. Subprojects for Part A 0.4 90% of amounts disbursed by MOH for each for Part B 0.6 subproject approved by MOH on or before for Part C 2.6 June 30, 1996 13. Unallocated 1.5 Total 15.0 Notes: Part A Inst. Strengthening of MOH Part D Rehab. & Maint. of Hospitals & Other Facil. Part B Primary Health Care Part E Technical Assistance to INSSBI Part C Pharmaceutical Supply System Estimated IDA Disbursements IDA Fiscal Year 1994 1995 1996 1997 Annual 1.51' 4.8 4.5 4.2 Cumulative 1.5 6.3 10.8 15.0 Includes the initial deposit of US$1.5 million to the Special Account and US$0.75 million of retroactive financing for eligible expenditures incurred after October 1, 1993. -9- Schedule C NICARAGUA HEALTH SECTOR REFORM PROJECT TIMETABLE OF KEY PROJECT PROCESSING EVENTS (a) Time taken to prepare 16 months (b) Prepared by Government with the assistance of IDA (c) First Bank mission July 1992 (d) Appraisal mission departure September 1993 (e) Negotiations November 1993 (g) Planned date of effectiveness March 1994 (g) List of relevant PCRs and PPARs Not applicable - 10 - Schedule D Page 1 of 2 NICARAGUA HEALTH SECTOR REFORM PROJECT STATUS OF BANK GROUP OPERATIONS IN NICARAGUA As of September 30, 1993 (US$ million) Credit/ Fiscal Amount ir US$ million (less cancellation) Loan No. Year Borrower Purpose Bank IDA Undisbursed 28 loans and 7 credits fully disbursed 229.6 18l. i Of which SECALs, SALs, and Programs Loans V Cr. 2302-NI 1992 Nicaragua Economic Recovery Credit 110.0 Cr. 2302-1-NI 1992 Nicaragua Economic Recovery Credit 10.3 Subtotal 120.3 Cr. 2302-2-NI 1993 Nicaragua Economic Rczovery Credit 8.5 8.7 (IDA 9th Replenishment) Cr. 2434-NI 1993 Nicaragua Social Investment Fund 25.0 22.9 Cr. 2536-NI 1993 Nicaragua Agricultural Technology & 44.0 44.0 Land Management Total 229.6 258.4 76.0 Of which has been repaid 169.7 5.2 Total now held by Bank and IDA 59.9 253.2Y Amount Sold 5.6 Of which has been repaid 5.6 Total Undisbursed 0.0 76.0 76.0 V Approved on or after FY80 / Difference due to exchange rate fluctuation between the SDR and US$ V Not yet effective. - 11 - Schedule D Page 2 of 2 NICARAGUA HEALTH SECTOR REFORM PROJECT STATEMENT OF IFC INVESTMENTS IN NICARAGUA As of September 30, 1993 (US$ million) Fiscal Original Gross Approvals (US$ Year Obligor Type of Business million) Committed IFC IFC Partici- Loan Equity pants iTotal 1968 Textiles F-bricato de Nicaragua, Textile Mill 0.07 1.07 0.93 2.07 S.A. (FABRITEX) 1976 Nicaragua Sugar Estates, Ltd. iY Sugar Mill Ji.50 -- -- 6.50 1976 Posada del Sol Hotel 0.70 0.20 -- 0.90 Total Gross Commitments A' 7.27 1.27 0.93 9.47 Less: Cancellations, terminations, repayments and sales 7.27 1.27 0.93 9.47 Total Commitments Now Held s' 0.00 0.00 0.00 0.00 Total Undisbursed Commitments 0.00 0.00 0.00 0.00 Investments which have been fully cancelled, terminated, written-off, sold, redeemed or repaid. I' Gross Commitments consist of approved and signed projects. 8' Held Commitments consist of disbursed and undisbursed investments. MAP SECTION NICARAGUA HONDURAS HEALTH SECTOR REFORM PROJECT Project SILAIS - SILAIS division boundaries Raiti Pn ® National capital Cities and towns International Boundaries Annay p4 LAGooN LsPuerto Cabeza JIO E AKJARATA L4.C00,, 12 -c~ A N.4 NUEVA «Santa SE GOVI A RA'Na'MUNaAR AGA N M A A CON Somoto La Vigia Kuiku~na c r ~Puertowe GULLF O E S T E L l FONSECA Esteil a" Somoillo MATA A 0 20 40 60 80 100 120 140 160 Morolpa ni _ _ _ _ _ _ _ _ _ _ _ _ _ ETER CHINANDEG LE ON RAAS 2E 80 100 Chinandeg BOA c 0 Corinto' Le62* la tibertad Ramla La·.IZ <2 5 e Puerto Sn HONDURAS S luigapa CHONTALES Bluefields MANAGUA ORIENTAL SnE EbaL MANAGUA CENTR AL i~ S ALVADOR MANAGUA CIDE TAL CAR( N ICA Man~g RIVANcAA'A $ . elancasa Area of Map P SAa Juan det NoStu r0NES SCOSTA Under the Primary Health Care component. R I C A .6 .4 .....